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Roff C, Cook-Cottone C. Assisted death in eating disorders: a systematic review of cases and clinical rationales. Front Psychiatry 2024; 15:1431771. [PMID: 39143961 PMCID: PMC11322357 DOI: 10.3389/fpsyt.2024.1431771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/12/2024] [Indexed: 08/16/2024] Open
Abstract
Background Assisted dying for reasons solely related to an eating disorder (ED) has occurred in multiple countries, including those which restrict the practice to individuals with a terminal condition. The aims of this systematic review were to (1) identify all known cases of assisted deaths among patients with EDs and (2) describe the clinical rationales used to grant patients' requests for assisted death. Methods We conducted a systematic search of peer-reviewed studies and publicly available government reports to identify cases of assisted death in patients with EDs. In reports that included qualitative data about the case, clinical rationales were extracted and grouped into domains by qualitative content analysis. Results We identified 10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024. Clinical rationales were categorized into three domains: irremediability, terminality, and voluntary request. Reports emphasized that patients with EDs who underwent assisted death had terminal, incurable, and/or untreatable conditions and had adequate decision-making capacity to make a life-ending decision. Most government reports did not include descriptive-enough data to verify psychiatric conditions. Conclusion The results of our systematic review underscore considerable gaps in the reporting of assisted death in patients with psychiatric conditions, posing substantial concerns about oversight and public safety. In many cases, the clinical rationales that were used to affirm patients with EDs were eligible for assisted death lack validity and do not cohere with empirical understanding.
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Affiliation(s)
| | - Catherine Cook-Cottone
- Department of Counseling, School, and Educational Psychology, University at Buffalo, Buffalo, NY, United States
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2
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Cogodi E, Ranieri J, Martelli A, Di Giacomo D. Emotional Dysregulation in Anorexia Nervosa: Scoping Review of Psychological Treatments. Healthcare (Basel) 2024; 12:1388. [PMID: 39057531 PMCID: PMC11276072 DOI: 10.3390/healthcare12141388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Eating disorders are complex psychiatric disorders characterized by compensatory and restrictive behavior and a preoccupation with one's body. Eating and purging behaviors are considered dysfunctional emotional regulation strategies. Therefore, psychological treatment is essential. The most common psychological interventions are dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), family therapy (FBT), multi-family group therapy (MFTG) and mentalization-based treatment (MBT). The aim of this study was to summarize the current evidence on the impact of psychological treatments on emotional regulation difficulties and psychological symptoms in patients with eating disorders, especially anorexia nervosa. A search was conducted on PubMed and Web of Science using the terms "anorexia nervosa" and "emotion dysregulation". Of the 278 initial articles, we included 15 publications. The results indicate that the acquisition of coping strategies, through DBT, leads to an improvement in anxiety and alexithymia. DBT, CBT and MBT lead to a reduction in the use of dysfunctional emotional regulation strategies too. Eating disorders involve both physical and mental health; therefore, it is desirable for future research to focus on the mutual synergy between the mental and physical components by evaluating various factors, such as biomarkers and the most appropriate therapeutic approach, with respect to the treatment setting.
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Affiliation(s)
- Enrica Cogodi
- Postgraduate in Clinical Psychology, University of L’Aquila, 67100 L’Aquila, Italy; (E.C.); (J.R.)
| | - Jessica Ranieri
- Postgraduate in Clinical Psychology, University of L’Aquila, 67100 L’Aquila, Italy; (E.C.); (J.R.)
- Life, Health and Environmental Sciences Department, University of L’Aquila, 67100 L’Aquila, Italy
| | - Alessandra Martelli
- Faculty of Biosciences and Agri-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy;
| | - Dina Di Giacomo
- Life, Health and Environmental Sciences Department, University of L’Aquila, 67100 L’Aquila, Italy
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Westmoreland P, Yager J, Treem J, Mehler PS. Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:344-349. [PMID: 38988464 PMCID: PMC11231468 DOI: 10.1176/appi.focus.20230035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Affiliation(s)
- Patricia Westmoreland
- ACUTE Center for Eating Disorders, Denver, Colorado (Westmoreland, Mehler); Department of Psychiatry (Westmoreland, Yager) and Department of Medicine (Mehler), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Mid-Atlantic Permanente Medical Group, Gaithersburg, Maryland (Treem); Eating Recovery Center, Denver, Colorado (Mehler)
| | - Joel Yager
- ACUTE Center for Eating Disorders, Denver, Colorado (Westmoreland, Mehler); Department of Psychiatry (Westmoreland, Yager) and Department of Medicine (Mehler), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Mid-Atlantic Permanente Medical Group, Gaithersburg, Maryland (Treem); Eating Recovery Center, Denver, Colorado (Mehler)
| | - Jonathan Treem
- ACUTE Center for Eating Disorders, Denver, Colorado (Westmoreland, Mehler); Department of Psychiatry (Westmoreland, Yager) and Department of Medicine (Mehler), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Mid-Atlantic Permanente Medical Group, Gaithersburg, Maryland (Treem); Eating Recovery Center, Denver, Colorado (Mehler)
| | - Philip S Mehler
- ACUTE Center for Eating Disorders, Denver, Colorado (Westmoreland, Mehler); Department of Psychiatry (Westmoreland, Yager) and Department of Medicine (Mehler), University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Mid-Atlantic Permanente Medical Group, Gaithersburg, Maryland (Treem); Eating Recovery Center, Denver, Colorado (Mehler)
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4
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Datta N, Hossepian K, Xie I, Gurcan HY, Behr S, Pouliadi M, Miranda C. Anorexia Nervosa Across the Lifespan: A Review of Recent Literature. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:269-277. [PMID: 38988469 PMCID: PMC11231474 DOI: 10.1176/appi.focus.20230037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
In this review, the authors provide an update on the understanding of anorexia nervosa (AN) across the lifespan. Focusing on key pieces of literature from the past 5 years, this review summarizes recent updates to DSM-5 within the domain of AN, including the addition of a new AN diagnosis: atypical anorexia. Additional sections covered in this review include improvements in the epidemiological understanding of AN across the developmental spectrum, treatment approaches that have been established as gold standard as well as new directions recently explored in treatment, and recent advancements in the biopsychosocial underpinnings of AN. Altogether, although this review captures several advancements in the field's overall conceptualization of AN, several key areas of treatment and diagnostic capacity continue to require additional focus and research.
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Affiliation(s)
- Nandini Datta
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Kristene Hossepian
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Isabella Xie
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Hazal Yagmur Gurcan
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Solveig Behr
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Marina Pouliadi
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
| | - Christina Miranda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Datta, Hossepian, Gurcan, Behr, Pouliadi, Miranda); Department of Psychiatry and Behavioral Sciences, Palo Alto University, Palo Alto, California (Xie); Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany (Behr)
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5
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Elwyn R, Adams M, Sharpe SL, Silverstein S, LaMarre A, Downs J, Burnette CB. Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality. J Eat Disord 2024; 12:70. [PMID: 38831456 PMCID: PMC11145809 DOI: 10.1186/s40337-024-01016-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.
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Affiliation(s)
- Rosiel Elwyn
- Neuroscience and psychiatry, Thompson Institute, Birtinya, QLD, Australia
- University of the Sunshine Coast, Birtinya, QLD, Australia
| | | | - Sam L Sharpe
- Fighting Eating Disorders in Underrepresented Populations (FEDUP, Collective), West Palm Beach, FL, USA
| | | | | | | | - C Blair Burnette
- Department of Psychology, Michigan State University, Lansing, MI, USA.
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6
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Reivan Ortiz GG, Campoverde X, Vinañzaca J, Estrada J, Yanza R, Granero R. Factors increasing the risk for food addiction in Ecuadorian students. Front Psychiatry 2024; 14:1214266. [PMID: 38234363 PMCID: PMC10792013 DOI: 10.3389/fpsyt.2023.1214266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 11/06/2023] [Indexed: 01/19/2024] Open
Abstract
Background Food addiction (FA) is a construct that has gained interest in recent years, but its relevance in the Ecuadorian population has not yet been explored. The aims of this study were to explore the differences in the psychological profile (including FA) between university students from Ecuador and to identify the underlying structure of the relationships of the FA severity level through a mediational model. Methods The sample consisted of 972 university students, women and men (mean age: 20.1 years old, SD = 2.6), recruited from four Ecuadorian regions. The assessment tools included a unidimensional scale of FA, eating-related measures, emotion regulation state, impulsivity, and psychopathology state. Path analysis modeled the direct and indirect effects explaining the FA severity level. Results The results indicated that higher psychopathological levels were associated with FA. Similarly, no differences in FA were observed between the Ecuadorian regions. The path analysis suggested that older age, female sex, and higher difficulties in emotional regulation, impulsivity, negative mood, and anxiety trigger disordered eating; subsequently, more impaired eating behavior impacted the FA level. Conclusion FA is a complex clinical entity that includes multiple components related to eating disorders (EDs) and other mental health problems. The results of this study provide empirical knowledge for designing evidence-based prevention and treatment strategies.
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Affiliation(s)
- Geovanny Genaro Reivan Ortiz
- Laboratory of Basic Psychology, Behavioral Analysis, and Programmatic Development (PAD-LAB), Catholic University of Cuenca, Cuenca, Ecuador
| | | | - Juan Vinañzaca
- Laboratory of Basic Psychology, Behavioral Analysis, and Programmatic Development (PAD-LAB), Catholic University of Cuenca, Cuenca, Ecuador
| | - Johanna Estrada
- Laboratory of Basic Psychology, Behavioral Analysis, and Programmatic Development (PAD-LAB), Catholic University of Cuenca, Cuenca, Ecuador
| | - Rafael Yanza
- Catholic University of Cuenca, Cuenca, Azuay, Ecuador
| | - Roser Granero
- Autonomous University of Barcelona, Barcelona, Spain
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7
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Kunasegaran K, Ismail AMH, Ramasamy S, Gnanou JV, Caszo BA, Chen PL. Understanding mental fatigue and its detection: a comparative analysis of assessments and tools. PeerJ 2023; 11:e15744. [PMID: 37637168 PMCID: PMC10460155 DOI: 10.7717/peerj.15744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/21/2023] [Indexed: 08/29/2023] Open
Abstract
Mental fatigue has shown to be one of the root causes of decreased productivity and overall cognitive performance, by decreasing an individual's ability to inhibit responses, process information and concentrate. The effects of mental fatigue have led to occupational errors and motorway accidents. Early detection of mental fatigue can prevent the escalation of symptoms that may lead to chronic fatigue syndrome and other disorders. To date, in clinical settings, the assessment of mental fatigue and stress is done through self-reported questionnaires. The validity of these questionnaires is questionable, as they are highly subjective measurement tools and are not immune to response biases. This review examines the wider presence of mental fatigue in the general population and critically compares its various detection techniques (i.e., self-reporting questionnaires, heart rate variability, salivary cortisol levels, electroencephalogram, and saccadic eye movements). The ability of these detection tools to assess inhibition responses (which are sensitive enough to be manifested in a fatigue state) is specifically evaluated for a reliable marker in identifying mentally fatigued individuals. In laboratory settings, antisaccade tasks have been long used to assess inhibitory control and this technique can potentially serve as the most promising assessment tool to objectively detect mental fatigue. However, more studies need to be conducted in the future to validate and correlate this assessment with other existing measures of mental fatigue detection. This review is intended for, but not limited to, mental health professionals, digital health scientists, vision researchers, and behavioral scientists.
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Affiliation(s)
- Kaveena Kunasegaran
- Department of Psychology, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | | | - Shamala Ramasamy
- Department of Psychology, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Justin Vijay Gnanou
- Department of Biochemistry, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Brinnell Annette Caszo
- Department of Physiology, International Medial University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Po Ling Chen
- School of Psychology, University of Nottingham Malaysia, Semenyih, Selangor, Malaysia
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8
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Mehler PS, Anderson K, Bauschka M, Cost J, Farooq A. Emergency room presentations of people with anorexia nervosa. J Eat Disord 2023; 11:16. [PMID: 36759897 PMCID: PMC9909152 DOI: 10.1186/s40337-023-00742-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
People with anorexia nervosa (AN) tend to shy away from engaging in typical primary care provider relationships in order to avoid detection. Therefore, they may seek care for their medical concerns through a local emergency department (ED). Inherently, AN is associated with a litany of medical complications, which become more prevalent as the severity of their eating disorder increases. Notwithstanding the typical young age at the onset of AN, no body system is immune to these medical complications. Thus, ED providers may need to pursue a medical diagnosis in order to explain presenting symptoms in people with AN. In addition to the medical issues, AN is also a serious mental illness with high mortality rates, including deaths by suicide. Therefore, ED providers also need to be familiar with relevant mental health issues for these people.
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Affiliation(s)
- Philip S Mehler
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA. .,University of Colorado School of Medicine, Denver, CO, USA.
| | - Kristin Anderson
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Colorado School of Medicine, Denver, CO, USA
| | - Maryrose Bauschka
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeana Cost
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,Eating Recovery Center, Denver, CO, USA
| | - Asma Farooq
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
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9
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van den Berg J, Elgersma H, Zeillemaker-Hoekstra M. Anorexia nervosa: practical implications for the anaesthetist. BJA Educ 2023; 23:17-23. [PMID: 36601024 PMCID: PMC9805935 DOI: 10.1016/j.bjae.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- J.P. van den Berg
- University of Groningen, University Medical Center Groningen, the Netherlands
| | - H.J. Elgersma
- Accare, Groningen, the Netherlands
- University of Groningen, the Netherlands
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10
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Keeler JL, Konyn CY, Treasure J, Cardi V, Himmerich H, Tchanturia K, Mycroft H. "Your mind doesn't have room for anything else": a qualitative study of perceptions of cognitive functioning during and after recovery from anorexia nervosa. J Eat Disord 2022; 10:201. [PMID: 36575533 PMCID: PMC9793561 DOI: 10.1186/s40337-022-00723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Past research has indicated the presence of cognitive difficulties in individuals with anorexia nervosa (AN), although it is unclear how these are experienced in real life. Moreover, it is unclear how and whether the experience of cognitive difficulties changes in nature and intensity over the course of the illness and following recovery. METHODS Twenty-one female participants (AN = 11; recovered AN = 10) participated in online semi-structured interviews, utilising open-ended questions and exploring topics relating to their experiences of their cognitive function, changes over time and their perspectives on the future. Reflexive thematic analysis was conducted on the resulting transcripts. RESULTS Six themes were identified, centred around the effects of the illness on mental and physical function, cognition, adaptation to living with the illness, similarities between AN and other psychopathology, tentative optimism for the future and recovery as a representation of liberation. Whilst respondents with AN appeared to perform remarkably well in their professional and educational lives, the cognitive difficulties were described as significantly impacting their ability to engage in life, particularly in the context of leisure and socialising. Respondents recovered from AN noted the importance of developing a non-AN identity as well as better emotion-regulation skills as central to recovery. CONCLUSIONS Whilst people with AN may be able to adapt their lives to the demands of the illness, they report significant cognitive difficulties that interfere with their engagement in many aspects of daily life. This should be considered by professionals working in the clinical management of AN. Treatments focused on ameliorating cognitive difficulties, and promoting emotional regulation and identity in AN are warranted.
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Affiliation(s)
- Johanna Louise Keeler
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 103 Denmark Hill, Section of Eating Disorders, London, SE5 8AF, UK.
| | - Carol Yael Konyn
- Department of Social, Genetic & Developmental Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8AF, UK
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 103 Denmark Hill, Section of Eating Disorders, London, SE5 8AF, UK.,Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
| | - Valentina Cardi
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 103 Denmark Hill, Section of Eating Disorders, London, SE5 8AF, UK.,Department of General Psychology, University of Padova, Padua, Italy
| | - Hubertus Himmerich
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 103 Denmark Hill, Section of Eating Disorders, London, SE5 8AF, UK.,Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
| | - Kate Tchanturia
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 103 Denmark Hill, Section of Eating Disorders, London, SE5 8AF, UK.,Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK.,Illia State University, Tbilisi, Georgia.,Psychological Set Research and Correction Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hazel Mycroft
- School of Psychology, University of Exeter, Exeter, Devon, UK
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11
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Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord 2022; 10:135. [PMID: 36068601 PMCID: PMC9450436 DOI: 10.1186/s40337-022-00659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Premature deaths are estimated to occur in 5-20% of patients with anorexia nervosa (AN). Among them, some patients with severe and enduring anorexia nervosa (SE-AN) will die due to the medical complications of malnutrition or to suicide. Almost no literature provides guidance to patients, clinicians, and loved ones regarding clinical characteristics of those with SE-AN who recognize and accept the fact that they will not be able to survive their disease. Consistent with general medical literature on terminal illness and based on the authors' work with patients at this phase of life, we previously described four clinical characteristics of the small group of SE-AN patients who may be considered to have a terminal eating disorder. Following publication of this article, several opinions objecting to these formulations were published. The goals of this article are to respond to the key themes of concern posed by these objections, to extend our discussion of the palliative care and associated needs of these patients and their families, and to suggest ways in which the eating disorder and palliative care fields might develop more definitive criteria and consensus guidelines for the assessment and management of these patients. METHODS Based on a selective narrative review of the literature, our combined experiences with these patients, and clinical reasoning, we address critiques grouped around five major themes: that (1) labels such as terminal AN are dangerous; (2) since AN is a treatable disorder, no SE-AN patients should be considered terminal; (3) a terminal psychiatric condition cannot be defined; (4) the proposed definition is not specific enough; and (5) considerations regarding mental capacity in the proposed criteria do not sufficiently account for the psycho-cognitive impairments in AN. RESULTS Our analysis responds to the critiques of our original proposed clinical characteristics of those with terminal AN. While refuting many of these critiques, we also appreciate the opportunity to refine our discussion of this complex topic and identify that there are multiple stages of SE-AN that can result in good clinical outcomes. Only when all of these have failed to provide adequate amelioration of suffering do a low number of patients progress to terminal AN. CONCLUSIONS By further refining our discussion of terminal AN, we aim to encourage eating disorders and palliative care specialists to develop expert consensus definitions for terminal AN and to generate authoritative clinical guidance for management of this population. By validating terminal AN as a distinct condition, patients with this subcategory of SE-AN, their families, and their caregivers facing end-of-life concerns may be better able to access palliative and hospice care and related services to help improve their overall experiences at this phase of life.
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Affiliation(s)
- Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jonathan Treem
- Department of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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12
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Takimoto Y. Key components of the mental capacity assessment of patients with anorexia nervosa: a study of three countries. J Eat Disord 2022; 10:110. [PMID: 35883210 PMCID: PMC9327278 DOI: 10.1186/s40337-022-00633-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment. METHODS A questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders. RESULTS A total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference. CONCLUSIONS It may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.
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Affiliation(s)
- Yoshiyuki Takimoto
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Tokyo, Japan. .,Department of Psychosomatic Medicine and Stress Science, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
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Takimoto Y. International comparison of physicians' attitudes toward refusal of treatment by patients with anorexia nervosa: a case-based vignette study. J Eat Disord 2022; 10:86. [PMID: 35739606 PMCID: PMC9230079 DOI: 10.1186/s40337-022-00613-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa. METHODS A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa. RESULTS For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient. CONCLUSIONS Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment.
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Affiliation(s)
- Yoshiyuki Takimoto
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
- Department of Psychosomatic Medicine and Stress Science, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
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14
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Riddle M, O'Melia AM, Bauschka M. First, do no harm: the proposed definition of "terminal anorexia" is fraught with danger for vulnerable individuals. J Eat Disord 2022; 10:81. [PMID: 35710504 PMCID: PMC9202193 DOI: 10.1186/s40337-022-00605-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
A recent article in the Journal of Eating Disorders (10:23, 2022) proposed criteria for "terminal anorexia" with a cited goal of improving access to end-of-life care (Gaudiani et al. in J Eat Disord 10(1):23, 2022). The authors presented three cases in which patients received end-of-life care, including the prescription of medical assistance in dying (MAID), also known as physician-assisted suicide (PAS). The proposed criteria lack the evidence base for adoption and do not acknowledge the compelling evidence that exists surrounding possible prolonged timelines to recovery for some individuals and the nuances of assessing capacity in this population.
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Affiliation(s)
- Megan Riddle
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Anne Marie O'Melia
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA
| | - Maryrose Bauschka
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA. .,Department of Psychiatry, University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA.
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15
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Guarda AS, Hanson A, Mehler P, Westmoreland P. Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined. J Eat Disord 2022; 10:79. [PMID: 35672780 PMCID: PMC9175496 DOI: 10.1186/s40337-022-00599-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
A recent article (JED 10:23, 2022) proposed defining terminal anorexia to improve access to palliative and hospice care, and to medical aid in dying for a minority of patients with severe and enduring anorexia nervosa (SE-AN). The authors presented three cases and, for two, the first author participated in their death. Anorexia nervosa is a treatable psychiatric condition for which recovery may be uncertain. We are greatly concerned however regarding implications of applying the label "terminal" to anorexia nervosa and the risk it will lead to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.
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Affiliation(s)
- Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA.
| | - Annette Hanson
- Department of Psychiatry, University of Maryland, Jessup, MD, 20794, USA
| | - Philip Mehler
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patricia Westmoreland
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA
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16
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Ten Napel-Schutz MC, Vroling M, Mares SHW, Arntz A. Treating PTSD with Imagery Rescripting in underweight eating disorder patients: a multiple baseline case series study. J Eat Disord 2022; 10:35. [PMID: 35264254 PMCID: PMC8908690 DOI: 10.1186/s40337-022-00558-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eating disorder patients with posttraumatic stress disorder have worse treatment results regarding their eating disorder than patients without posttraumatic stress disorder. Many eating disorder patients with co-morbid posttraumatic stress disorder symptoms are not treated for posttraumatic stress disorder symptoms during an underweight state. We propose that treatment of posttraumatic stress disorder is possible for underweight patients and that their trauma symptoms decrease with the use of Imagery Rescripting. We also investigated whether treatment of trauma influences eating disorder pathology in general and the process of weight gain specifically. METHOD Ten patients in clinical treatment (BMI 14-16.5) participated. A multiple baseline design was used, with baseline varying from 6 to 10 weeks, a 6-week treatment phase, a 3-week follow-up period and a 3-month follow-up measurement. Data were analysed with mixed regression. RESULTS Evidence was found that Imagery Rescripting had strong positive effects on posttraumatic stress disorder symptoms without interfering with eating disorder treatment. Positive effects were also found on a range of secondary emotional and cognitive measures. CONCLUSION Imagery Rescripting of traumatic memories is a possible and safe intervention for underweight eating disorder patients. It also had positive clinical effects. Trial registration Netherlands trial register (NTR) Trial NL5906 (NTR6094). Date of registration 09/23/2016. https://www.trialregister.nl/trial/5906 .
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Affiliation(s)
- Marieke C Ten Napel-Schutz
- Department of Eating Disorders (Amarum), GGNet Mental Health, Warnsveld, The Netherlands.
- Radboud Centre Social Science, Radboud University, Nijmegen, The Netherlands.
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.
| | - Maartje Vroling
- Department of Eating Disorders (Amarum), GGNet Mental Health, Warnsveld, The Netherlands
| | - Suzanne H W Mares
- Department of Eating Disorders (Amarum), GGNet Mental Health, Warnsveld, The Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
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17
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Di Lodovico L, Versini A, Lachatre M, Marcheselli J, Ramoz N, Gorwood P. Is decision-making impairment an endophenotype of anorexia nervosa? Eur Psychiatry 2022; 65:e68. [DOI: 10.1192/j.eurpsy.2022.2327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Patients with anorexia nervosa (AN) show impaired decision-making ability, but it is still unclear if this is a trait marker (i.e., being associated with AN at any stage of the disease) or a state parameter of the disease (i.e., being present only in acutely ill patients), and if it has endophenotypic characteristics. The aim of this study was to determine the endophenotypic, and state- or trait-associated nature of decision-making impairment in AN.
Methods
Ninety-one patients with acute AN (A-AN), 90 unaffected relatives (UR), 23 patients remitted from AN (R-AN), and 204 healthy controls (HC) carried out the Iowa gambling task (IGT). Prospective valence learning (PVL) model was employed to distinguish the cognitive dimensions underlying the decision-making process, that is, learning, consistency, feedback sensitivity, and loss aversion. IGT performance and decision-making dimensions were compared among groups to assess whether they had endophenotypic (i.e., being present in A-AN, UR, and R-AN, but not in HC) and/or trait-associated features (i.e., present in A-AN and R-AN but not in HC).
Results
Patients with A-AN had lower performance at the IGT (p < 0.01), while UR, R-AN, and HC had comparable results. PVL-feedback sensitivity was lower in patients with R-AN and A-AN than in HC (p < 0.01).
Conclusions
Alteration of decision-making ability did not show endophenotypic features. Impaired decision-making seems a state-associated characteristic of AN, resulting from the interplay between trait-associated low feedback sensitivity and state-associated features of the disease.
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18
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Broomfield C, Stedal K, Touyz S. The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review. Front Psychol 2021; 12:708536. [PMID: 34408714 PMCID: PMC8365190 DOI: 10.3389/fpsyg.2021.708536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Characteristics of Severe and Enduring Anorexia Nervosa (SE-AN) are being investigated to differentiate the patients experiencing SE-AN from those at earlier stages of the AN disease. The current systematic review was the first step in exploring neuropsychological functioning as a potentially identifying characteristic for long-term presentations. With a subgroup of AN patients reflecting a unique neuropsychological profile that is proportionate to the quantity of patients that go on to develop SE-AN, it was the aim of this review to assess neuropsychological functioning in the later stage of the disease. In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science, and Scopus) for neuropsychological research on AN participants with a seven or more year illness duration. Datasets that met inclusion criteria were screened for SE-AN participants (N = 166) and neuropsychological data extracted together with potentially confounding variables and information required to conduct a quality assessment. In research investigating decision-making, participants with a SE-AN presentation demonstrated significantly lower functioning compared to healthy controls. There was conflicting evidence for differences in intellectual functioning and set-shifting abilities with no variability indicated in central coherence, memory, attention, reasoning, or processing speed. If findings from this preliminary analysis are confirmed through empirical research, implications include earlier identification of SE-AN patients and more effective treatment development.
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Affiliation(s)
| | - Kristin Stedal
- Regional Department for Eating Disorders, Oslo University Hospital, Ullevål, Norway
| | - Stephen Touyz
- Inside Out Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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19
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Yager J. Why Defend Harm Reduction for Severe and Enduring Eating Disorders? Who Wouldn't Want to Reduce Harms? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:57-59. [PMID: 34152907 DOI: 10.1080/15265161.2021.1926160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Joel Yager
- University of Colorado School of Medicine
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20
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Riquin E, Raynal A, Mattar L, Lalanne C, Hirot F, Huas C, Duclos J, Berthoz S, Godart N. Is the Severity of the Clinical Expression of Anorexia Nervosa Influenced by an Anxiety, Depressive, or Obsessive-Compulsive Comorbidity Over a Lifetime? Front Psychiatry 2021; 12:658416. [PMID: 34279519 PMCID: PMC8280337 DOI: 10.3389/fpsyt.2021.658416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/29/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose: The relationship between anxiety or depressive comorbidities, their chronology of onset, and the severity of anorexia nervosa (AN) is not well-studied. We hypothesize that the existence of a comorbidity, particularly before the onset of AN, is associated with greater severity of AN. Methods: One hundred seventy-seven subjects were assessed. The prevalence of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and social phobia (SP) as well as their chronology of onset were studied. The assessment criteria of AN severity were the overall clinical condition, body mass index (BMI) on admission, lowest BMI, intensity of the eating symptoms, age at the onset of AN, illness duration, number of hospitalizations, and quality of life. Results: Patients with AN had the greatest clinical severity when they had a comorbid disorder over their lifetime, such as MDD, GAD, or SP. These comorbidities along with OCD were associated with a higher level of eating symptoms and a more altered quality of life. A profile of maximum severity was associated with a higher prevalence of MDD and GAD. Concerning the chronology of onset, the age at the start of AN was later in cases of MDD or GAD prior to AN. Conclusion: There seems to be an association between severity of AN and both MDD and GAD. The chronology of onset of the comorbidity did not seem to be associated with the severity.
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Affiliation(s)
- Elise Riquin
- Department of Child and Adolescent Psychiatry, Centre Hospitalier Universitaire d'Angers [Angers University Hospital], Angers, France
- Laboratory of Psychology, LPPL EA4638, University of Angers, Angers, France
- Adolescent and Young Adult University Hospital Department of the Health Foundation of Students of France, Centre Pierre Daguet, Sablé-sur-Sarthe, France
| | - Agathe Raynal
- Department of Child and Adolescent Psychiatry, CH du Rouvray-CHU de Rouen, Rouen, France
| | - Lama Mattar
- Nutrition Division, Department of Natural Sciences, School of Arts and Sciences-Lebanese American University, Beirut, Lebanon
| | - Christophe Lalanne
- Université Paris Diderot [Paris Diderot University], Paris Sorbonne Cité, Paris, France
| | - France Hirot
- CESP, Univ. Paris-Sud, UVSQ, INSERM U 1178, Université Paris-Saclay [Paris-Saclay University], Paris, France
- Department of Psychiatry for Adolescents and Young Adults, Institut Mutualiste Montsouris, Paris, France
| | - Caroline Huas
- CESP, Univ. Paris-Sud, UVSQ, INSERM U 1178, Université Paris-Saclay [Paris-Saclay University], Paris, France
- Adolescent and Young Adult University Hospital Department of the Health Foundation of Students of France, Paris, France
| | - Jeanne Duclos
- Univ. Lille, CNRS, CHU Lille, UMR 9193—SCALab—Cognitive and Affective Sciences, Lille, France
- Hôpital Saint Vincent de Paul, GHICL, Département de Psychiatrie, Paris, France
| | - Sylvie Berthoz
- Department of Psychiatry for Adolescents and Young Adults, Institut Mutualiste Montsouris, Paris, France
- Univ. Bordeaux INCIA CNRS UMR 5287, Bordeaux, France
| | - Nathalie Godart
- CESP, Univ. Paris-Sud, UVSQ, INSERM U 1178, Université Paris-Saclay [Paris-Saclay University], Paris, France
- Department of Psychiatry for Adolescents and Young Adults, Institut Mutualiste Montsouris, Paris, France
- Adolescent and Young Adult University Hospital Department of the Health Foundation of Students of France, Paris, France
- UFR des Sciences de la Santé Simone Veil [Simone Veil Health Science Training and Research Unit], Université de Versailles Saint-Quentin-en-Yvelines [Versailles Saint-Quentin-en-Yvelines University], Versailles, France
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21
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Speciani M, Barak Y, Damanhuri H, De Ronchi D, Panariello F, Atti AR. A Perspective on Chronic and Long-Lasting Anorexia Nervosa. Front Psychiatry 2021; 12:756669. [PMID: 34777061 PMCID: PMC8585925 DOI: 10.3389/fpsyt.2021.756669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022] Open
Abstract
Anorexia Nervosa (AN) is a severe eating disorder which typically develops in younger females. Many studies focus on this specific population, a majority of which will eventually partially or fully recover. A minority will become chronic despite extensive treatment. These patients are treatment-resistant and may not necessarily benefit from usual treatment. In this article we will reflect on possible mechanisms which may explain the maintenance of disease, and especially on the possible role of affective and anxiety disturbances. We will use, due to the lack of large-scale studies, data from risk and prognostic factors, treatment options and neurobiological correlates in chronic AN patients. Lastly, we will propose how these elements may advise further research and treatments.
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Affiliation(s)
- Maurizio Speciani
- Department of Biomedical and Neuromotor Sciences, Psychiatry, Bologna University, Bologna, Italy
| | - Yoram Barak
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Hanafi Damanhuri
- Department of Biochemistry, Faculty of Medicine, UKM Medical Centre, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Diana De Ronchi
- Department of Biomedical and Neuromotor Sciences, Psychiatry, Bologna University, Bologna, Italy
| | - Fabio Panariello
- Department of Biomedical and Neuromotor Sciences, Psychiatry, Bologna University, Bologna, Italy
| | - Anna Rita Atti
- Department of Biomedical and Neuromotor Sciences, Psychiatry, Bologna University, Bologna, Italy
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